Clinical Flashcards
1
Q
What is osteoarthiritis?
A
Articular cartilage thinning or loss
commonly called “wear & tear” in the joints
2
Q
what are the risk factors for osteoarthritis?
A
Age male sex Obesity Previous injury Occupation Sports activities Muscle weakness Proprioceptive deficits Genetic elements Acromegaly Joint inflammation Crystal deposition in cartilage
3
Q
What are the two main types of OA?
A
Primary/idiopathic
Secondary
4
Q
what are the main causes of secondary OA?
A
Joint disease
Haemochromatosis
Obesity
Calcium crystal deposition disease
occupational related
5
Q
What are the main sites of OA?
A
Knees or Hip are Main ones
others:
spine ( cervical or lumbar)
HAND (DIP,PIP, 1st IP, 1st MCP, CMC)
FOOT ( MTP joint)
6
Q
What are the signs and symptoms of OA?
A
- Localised disease ( often knee and hip):
Pain and creptius on movement. Made worse on prolonged activity
Stiffness
joint effusion
restriction of movement
Hip pain - Pain may be felt in groin or radiating to knee
- Generalised disease : Nodal OA (typically hand joints)
Tenderness
derangement and bone swelling
7
Q
How do you diagnose OA?
A
1.Radiography shows:
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
2.Kellgren-Lawrence Radiographic Grading Scale of Osteoarthritis:
Grade 0-No radiographic findings of osteoarthritis
Grade 1- Minute osteophytes of doubtful clinical significance
Grade 2 - Definite osteophytes with unimpaired joint space
Grade 3 - Definite osteophytes with moderate joint space narrowing
Grade 4 - Definite osteophytes with severe joint space narrowing and subchondral sclerosis
8
Q
How do you manage OA?
A
Exercise to improve local muscle strength and general aerobic fitness
weight loss if overweight
Pharmacological:
- Analgesia - Paracetamol +/- topical NSAIDs
- If Paracetamol and topical NSAID are ineffective then add oral NSAID/COX-2 inhibitor to paracetamol should be considered. Use PPI for either
- Intra-articular steroid injections for temporary relief if there are severe symptoms
Surgery:
- Joint replacements
- Arthroscopic washout, Loose body, soft tissue trimming.
9
Q
What is gout?
A
Inflammation in the joint triggered by uric acid crystals
10
Q
what are the main causes and risk factors for gout?
A
Deposition of monosodium urate crystals in and near joints
- Reduced Urate excretion: Elderly, men, post-menopausal women, impaired renal function, hypertension, aspirin and Diuretics
- Excess urate production: Dietary (alcohol, sweeteners and seafood/red meat), genetic disorders, Myeloproliferative/Lymphoproliferative disorders and psoraisis
11
Q
What are the most common sites effected by gout?
A
- Metatarsophalangeal joint of the big toe
2. Ankle, foot, small joints of the hand, wrist, elbow or knee
12
Q
What are the signs and symptom of Gout?
A
Acute monoarthropathy with severe joint inflammation
Acute Gout:
Settles in about 10 days without treatment
Settles in about 3 days with treatment
Abrupt onset, often overnight
May have normal uric acid during acute attack
Chronic gout: Chronic joint inflammation Often diuretic associated High serum uric acid Tophi May get acute attacks
13
Q
How do you diagnose Gout?
A
- Needle-shaped monosodium urate crystals found in negative birefringence under polarised light in synovial fluid
- Serum Urate (SUA) raised. Might be normal in acute attack
- Inflammatory markers
- punched out erosions in juxta-articular bone
14
Q
How do you manage Gout?
A
1.Acute gout:
High-dose NSAID if contraindication use Colchicine which is slower
- Prevention: lose weight, avoid prolonged fasts, avoid purine rich meats and avoid low dose aspirin
- Prophylaxis e.g. allopurinol or Febuxostat
15
Q
What is Calcium pyrophosphate deposition (CPPD)?
A
two types:
- Calcium pyrophosphate
- Calcium hydroxy appatite crystals (pseudogout)
16
Q
What are the risk factors of CPPD?
A
Elderly
usually spontaneous but can be provoked by illness, surgery or trauma
hyperparathyroidisim
Haemochromatosis
17
Q
What are the signs and symptoms of CPPD?
A
Acute monoarthropathy usually of larger joints in elderly
Chronic CPPD inflammatory RA like (symmetrical) polyarthritis and synovitis
18
Q
How do you diagnose CPPD?
A
Needle-shaped monosodium urate crystals found in positivie birefringence under polarised light in synovial fluid
associated with soft tissue calcium deposition on X-ray
19
Q
How do you manage CPPD?
A
Acute Attacks: cool packs, rest, aspiration and intra-articular steroids. NSAIDs (+PPI)
Methotrexate or hydroxychloroquine for chronic CPP inflammatory arthritis
20
Q
what is Hydroxyapatite?
A
Hydroxyapatite crystal deposition in or around the joint. There is acute and rapid deterioration
commonly in the shoulder joint
21
Q
How do you diagnose Hydroxyapatite?
ii. what is the main epidemiology?
A
Release of collagenases, serine proteinases and IL-1
ii. Females, 50-60 years
22
Q
How do you manage Hydroxyapatite?
A
NSAIDs
Intra-articular steroid injection
Physiotherapy
Partial or total arthroplasty
23
Q
What is the modified Beighton score?
A
> 10º hyperextension of the elbows
Passively touch the forearm with the thumb, while flexing the wrist.
Passive extension of the fingers or a 90º or more extension of the fifth finger
Knees hyperextension ≥ 10º)
Touching the floor with the palms of the hands when reaching down without bending the knees.
Hypermobility if ≥ 4/9
24
Q
What is soft tissue rheumatism?
A
pain that is caused by inflammation/damage to ligaments, tendons, muscles or nerve near a joint rather than either the bone or cartilage
25
What is the most common areas for soft tissue rheumatism?
Shoulder
```
e.g. Adhesive Capsulitis
Rotator cuff tendinosis
Calcific tendonitis
Impingement
Partial rotator cuff tears
Full rotator cuff tears
```
26
How do you diagnose and manage Soft tissue rheumatism?
```
1.Diagnose
Tests are usually unnecessary
X-ray - calcific tendonitis
MRI if fails to settle
Identify precipitating factors
```
```
2.management
Pain control
Rest and Ice compressions
PT
Steroid injections
Surgery
```
27
what is vasculitis?
it is inflammation of the blood vessels
presentation depends on the organs involved
28
What is difference between primary and secondary vasculitis?
primary - results from an inflammatory response that has no known cause or is autoimmune
secondary- inflammation of the blood vessels caused by a known cause
29
What are the main causes of secondary vasculitis?
SLE
Rheumatoid arthritis
Hep B&C
HIV
30
What is the pathophysiology of vasculitis?
1. Activated dendrite cells express receptors and release inflammatory cytokines that promote activation of T cells and vascular inflammation.
2. Activated T cells promotes inflammation, granuloma formation and macrophage activation and differentiation
3. Activated macrophages produce a variety of mediators that lead to progressive vascular inflammation, endothelial damage, disruption of the internal elastic lamina, and intimal hyperplasia.
31
How do you classify vasculitis?
Via size of blood vessel:
Large vessel: Giant cell arteritis and takayasu arteritis
Medium-vessel: Polyarteritis nodosa, kawasaki disease
small-vessel: split into two groups ANCA-associated and immune complex
ANCA-associated: Microscopic polyangitis, Granulomatosis with polyangitis ( wegener) and Eosinophilic granulomatosis with polyangitisis (churg-strauss)
Immune complex: Goodpasture's disease, IgA vasculitis ( Henoch-schonlein)
32
What are the signs and symptoms of Vasculitis?
Depends on the type of which vessels affected
Systemic symptoms: Fever, malaise , weight loss, arthlagia and myalgia
Skin: Purpura, ulcers, liverdo reticularis, nail bed infarcts
Eyes: scleritis, visual loss
ENT: Epistaxis, nasal crushing , stridor , deafness, sinusitis or mouth ulcers
Pulmonary: Haemoptysis , dyspnoea and caviating nodules on CXR
Cardiac: Angina or MI, heart failure and pericarditis
GI: pain or perfoartion
Neurological: Stroke, fits, chorea, psychosis, confusion
Renal: Hypertension, haematuria, proteinuria, casts and renal failure
33
How do you diagnose Vasculitis?
MR angiogram or PET CT
Temporal artery biopsy - remember "skip lesions" occur so biopsy may be negative
ESR/CRP increase
ANCA may be positive - use immunofluorescence
Creatine levels increase if renal failure
urine: proteinuria, haematuria - urinanalysis
34
How do you manage Vasculitis?
Large- vessel:
1. Prednisolone
2. Steroid sparing agents may be considered
Medium/small vessel:
1. immunosuppression ( steroids +/- another agents)
e. g. Cyclophosamide if severe or methotrexate/azathioprine
35
What is Henoch-schlonlein purpura ( HSP)?
Henoch-Schönlein purpura (HSP) affects the blood vessels and causes a spotty rash
36
What is the main cause of HSP?
group A streptococcus
mainly preceded by URTI, Pharyngeal infection or GI infection
37
What are the signs and symptoms of HSP?
Purpuric rash typically over buttocks and lower limbs
colicky abdominal pain
bloody diarrhoea
Joint pain ( may have sweeling)
Renal involvement issues ( 50% of patients)
38
How do you manage HSP?
usually self- limiting
symptoms tend to resolve within 8 weeks but relapse can occur
39
Which types of Vasculitis are positive for cANCA?
Granulomatosis with Polyangitis (GPA)
40
which types of vasculitis are positive for pANCA?
EGPA - eosinophilic granulomatosis with polyangitis
Microscopic Polyangitis (MPO)
41
What is Giant cell arteritis/ temporal arteritis?
form of vasculitis common in the elderly (over 55)
42
what are the signs and symptoms of GCA?
Headache
temporal artery
scalp tenderness
tongue/jaw claudication
amaurosis fugax - loss of eyesight in one or two eyes due to lack of blood flow
Extracranial symptoms: malaise, dyspnoea, weight loss, morning stiffness
43
How do you diagnose GCA?
Huge rise in ESR/CRP
Platelet increase
ALP increase
Hb decrease
temporal artery biopsy- skip lesions do occur so may be negative
PET scan
44
How do you manage GCA?
Prednisolone immediately or IV methylprednisolone if evolving visual loss or history of amaurosis fugax
Give PPI, Biphosphate, calcium with coleciferol and aspirin
45
what is polyarteritis nodosa (PAN)?
necrotising vasculitis that causes aneurysms and thrombosis, leading to infarction in affected organs with severe systemic symptoms
more common in men
46
Which organs are least associated with PAN?
Lungs
47
what is microscopic polyangititis? (MPO)
Necrotising vasculitis affecting small and medium sized vessels.
48
What are the signs and symptoms of MPO?
rapidly progressive glomerulonephritis
and pulmonary haemorrhoages are common
plus normal symptoms of vasculitis
49
What is Rheumatoid arthritis?
Chronic systemic inflammatory disease, characterised by a symmetrical, deforming, peripheral polyarthritis
50
What is the epidemiology RA?
women 3 times more likely than men
can affect any age group - most common starts at 50s/60s
prevalence is 1%
51
What is the pathogenesis of RA?
main triggers are smoking and infections
severity based upon genetic factors and presence of auto- antibodies
52
What are the main sites affected by RA?
Synovium structures of joints most affected
small joints in hands and feet most common. However large joints may be involved
writsts, elbows,shoulders, knees, hips and ankles are also examples of joints affected
53
what are the signs and symptoms of RA?
symmetrical swollen, painful stiff small joints of hands and feet (PIPs/MCPs and MTPs)
prolonged morning stiffness
2. less common presentations: sudden onset, widespread arthritis
systemic illness may occur: e.g. fatigue, malaise and weight loss
3. later signs of RA: Joint damage/deformity, Ulnar deviation and subluxation of the wrist and fingers or Z-deformity of thumbs occur.
4. Extra-articular mainfestations: Nodule found on elbows, lungs (ILD, bronchiectasis , pulmonary fibrosis and PE), cardiac, CNS and vasculitis
Lung: pleural disease, interstitial fibrosis
Cardiac: IHD, Pericarditis, perifardial effusion
Eye: Scleritis, episcleritis and keratoconjunctivitis
54
How do you diagnose RA?
1.auto antibodies
Rheumatoid factor: Sensitivity 50-80%
Specificity 70-80%
Antibodies to cyclic citrullinated peptide (Anti-CCP antibodies):
Sensitivity 60-70%
Specificity 90-99%
2. ESR/CRP increase and platelet levels rise
3. Imaging:
X-rays:
Early disease:
Normal
Soft tissue swelling
Periarticular osteopenia.
Late disease:
Erosions
Subluxation
US:
Increased sensitivity for synovitis in early disease
Consistently superior to clinical examination
Can detect more MCP erosions than plain x-ray in early RA
Useful in making treatment changes
55
How do you manage RA?
1. Disease activity measured using 28-joint disease activity score
2. Give early use of Disease modifying anti-rheumatic drugs (DMARDS) e.g. Methotrexate 1st choice, Sulfasalazine, Leflunomide, Hydroxychloroquine mainly for lupus and steroids
3. Steroids rapidly reduce symptoms and inflammation.
4. NSAIDS for symptom relief but no effect on disease
5. Biologics: give when Tried 2 DMARDs
DAS 28 score >5.1
```
e.g. Anti TNF agents- Infliximab, Etanercept, Adalimumab.
T cell receptor blocker-Abatacept.
B cell depletor-Rituximab
IL-6 blocker-Tocilizumab.
JAK inhibitors-Tofacitinib, Baricitinib
```
56
what are the side effects of DMARDs?
```
Bone marrow suppression
Infection
Liver function derangement
Pneumonitis
Nausea
```
57
What is systemic lupus erythematosus (SLE)?
Multisystemic autoimmune disease. Auto-antibodies are made against a variety of autoantigens which form immune complexes
58
What is the epidemiology of SLE?
0. 2% of population
9: 1 women:men
commoner in Afro-Caribbean, Asians and Hispanic-Americans
59
What is the pathogenesis of SLE?
1. Loss of immune regulation
2. increased and defective apoptosis
3. Necrotic cells release nuclear materials which act as auto-antigens
4. Auto-immunity results from exposure to nuclear and cellular auto-antigens
5. B and T cells are stimulated
6. Auto-antibodies are produced
7. Complexes of antigens and auto-anbodies form and circulate
8. deposition of immune complexes in basement membrane
9. cytokine release perpetuates inflammation which causes necrosis and scarring
60
What are the signs and symptoms of SLE?
SLE mimics other illnesses
EULAR/ACR 2019 SLE classification criteria:
1. ANA must be positive
2. Score >10
Clinical criteria:
1. Constitiutional domain: fever, malaise, myagia and fatigue
2. Cutaneous domain:
Nonscarring alopecia, oral ulcers, subacute cutaneous lupus (Malar rash), Chronic cutanoeus lupus (discoid rash)
3. Arthritis domain: Synovitis
4. Neurologic domain: delirium, psychosis, seizure
5. Serositis domain: pleural or pericardial effusion, acute pericarditis
6. Haematoligical domain: leukopenia, thrombocytopenia and autoimmune haemolysis
7. renal domain: proteinuria >0.5g/24hr, class II lupus nephritis, class III lupus nephritis
61
What is the difference between malar rash and discoid rash?
Malar rash - red fixed erythema rash ,flat or raised over the malar eminences. spares the nose
Diiscoid rash - red/white rash erythematous raised patches with adherent keratotoic scales. three staged rash
62
What are the immune criteria for SLE?
1. +ve ANA ( positive in 95% of cases)
2. Anti- dsDNA - highly specific ( only in 60% of cases)
3. Anti-smooth antibodies present
4. Antiphospholipid antibodies present
5. Low C3 and/or C4
63
How do you diagnose SLE?
Mainly through criteria
when monitoring three best tests:
1. Anti-dsDNA antibody titres
2. Complement proteins
3. ESR
64
How do you manage SLE?
general: Sun protection, vaccinations, exercise, no smoking, lose weight, monitor blood pressure, lipids and glucose
1. Mild
1st line: Hydroxychloroquine, Glucorticosteroids oral/intramuscular
refractory: Hydroxychloroquine, Glucorticosteroids oral/intramuscular and Methotrexate/azathioprine
2. Moderate
1st line: Hydroxychloroquine, Glucorticosteroids oral/intramuscular and Methotrexate/azathioprine,, calcineurin inhibitors and cyclophosphamide
Refractory: Hydroxychloroquine, Glucorticosteroids oral/intramuscular and Methotrexate/azathioprine,, calcineurin inhibitors , mycophenolate mofeti and belimumab
3. Severe
1st line: Hydroxychloroquine, Glucorticosteroids oral/intramuscular, cyclophosphamide and mycophenolate mofeti
refractory: Hydroxychloroquine, Glucorticosteroids oral/intramuscular, cyclophosphamide and rituximab
65
What is Sjogren's syndrome?
A chronic inflammatory autoimmune disorder. Which can be primary or secondary.
66
what is the epidemiology of Sjorgren's syndrome?
(9:1 women:men) onset 4th- 5th decade
67
What are the signs and symptoms of Sjorgren's symptom?
Dry eyes and kertoconjunvitivis - decrease in tear production
Dry mouth (xerostomia) - decrease in saliva production
Dry throat
Vaginal dryness
Bilateral parotid gland swelling
Joint pain
fatigue
Unexplained increase in dental caries
68
How do you diagnose Sjorgren's?
Schrimer's test measure conjunctival dryness
Immunology: anti-Ro and Anti-La (26% and 40%)
ANA is usually +ve
RF can be +ve (40% of cases)
May have raised IgG and raised ESR
69
What does Sjogren increase the risk of?
Lymphoma
70
What is systemic sclerosis?
Is a multisystem autoimmune disease which features scleroderma (Skin fibrosis), internal organ fibrosis and mircrovascular abnormalities
71
What are the signs and symptoms of Systemic sclerosis?
Raynaud's syndrome
Skin thickening
Difficulty swallowing
GORD
telangiectasia- widened venules cause threadlike red lines or patterns on the skin
calcinosis
may have SOB
Two types of SLE
1. Diffuse: Skin involvement on extremities above & below elbows and knees ( plus face and trunk). i.e. whole body
2. Limited: Face hand and feet. i.e. rule is below elbows and knees (plus face). associated with pulmonary hypertension
72
what antibodies are assoicated with limited systemic sclerosis?
Anticentromere antibodies
Anti-To/Th
73
What antibodies are associated with diffuse systemic scleorsis?
Anti-topoisonmerase-1 antibodies
anti-RNA polymerase
74
what are the main GI complications associated with systemic sclerosis?
1. Dysphagia
2. GORD
3. Watermelon stomach
4. Small intestinal bacterial overgrowth
5. Malabsorption
6. Fluctuating bowel habit
7. Faecal incontinence
75
What are the main cardio and resp complications associated with Systemic scleorsis?
1. Interstitial lung disease
2. Pulmonary arterial hypertension
3. Myocardial disease
76
What are the main renal complications associated with systemic sclerosis?
Scleroderma renal crisis
Non specific progessive renal dysfunction
77
What are the three main clinical features of Raynaud's phenomemen?
best seen on hands
1. Blanching - white
2. Acricyanosis - purple
3. Reactive hyperaemia- redness
78
How do you manage systemic sclerosis?
No cure
1. Management of Raynaud's
CCBs ( nifedipine usually first line treatment)
ARBs and nitrates
PDE-5 inhibitor ( e.g. sildenafil)
Prostacyclin infusion (e.g. iloprost)
Endothelin receptor antagonist (e.g. Bosentan)
2. Management of Pulmonary hypertension
screen every year
use immunosupression:
Myophenolate mofetil
Rarely cyclophosphamide ( for very aggressive disease)
Rixtuximab as a second line agent
Nintedanib- antifibrotic
3. Management of renal disease
Regular ACE or ARBS decrease risk of renal issue
monitor BP and renal function
4. Management of skin fibrosis
methotrexate and mycophenolate
79
Give examples of causes for "mechanical" back pain.
1. Obesity
2. poor posture
3. Poor lifting technique
4. Lack of physical activity
5. Depression
6. Degenerative disc prolapse
7. Facet Joint OA
8. Spondylosis
80
What is spondylosis?
Where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA
81
How do you manage "mechanical" back pain?
Analgesia
physiotherapy
reassure patents that it is not a serious problem
do not advise bed rest - lead to stiffness and spasm
spinal stabilisation surgery - if patient hasn't improved from physiotherapy and is affected by OA or instability
82
How can an acute disc tear occur?
Occurs in the outer annulus fibrosis of an intervertebral disc which normally happens after lifting a heavy object
83
What are the symptoms of an acute disc tear?
severe back pain
made worse on coughing - increases disc pressure
symptoms resolve after 2-3 months after
84
How do you manage an acute disc tear?
Analgesia and physiotherapy
85
What is spinal stenosis?
when the cauda equina of the lumbar spine has less space causes multiple nerve roots to become compressed
86
Give examples of causes for spinal stenosis.
Spondylosis
bulging discs
bulging ligamentum flavum
osteophytosis
87
What is the main clinical features of spinal stenosis?
patients usually over 60
Claudication- different to PVD claudication:
1. Claudication distance is inconsistent
2. Pain is burning rather than cramping like in PVD
3. Pain is less walking uphill but worse walking downhill
4. Pedal pulses are preserved
88
How do you diagnose spinal stenosis?
MRI
89
How do you manage spinal stenosis?
Conservative management ( analgesia, physiotherapy and weight loss)
If MRI shows stenosis then surgery can help to increase space for cauda equina
90
What is cauda equina syndrome?
When a very large central disc prolapse compress all the nerve roots of the cauda equina
91
What are the sign and symptoms of cauda equina?
Bilateral leg pain symptoms and altered bladder/bowel function is cauda equina syndrome until proven otherwise
Bilateral leg pain
Paraesthesiae or numbness.
Numbing common around the sitting area and perineum (saddle anaesthesia)
urinary retention and faecal inconteninence can occur
92
How do you diagnose cauda equina syndrome?
1. PR examination - mandatory
| 2. urgent MRI
93
How do you manage Cauda equina syndrome?
urgent Discetomy
94
Give examples of Red flag symptoms for Back pain.
1. Back pain in the younger patients <20 - children more susceptible to infection.
2. New back pain in the older patients <60 - higher risk of arthritic change, crush fracture or malignancy
3. Nature of pain : constant severe pain which is worse at night - Tumour and infection main cause of this complaint
4. Sytemic upset : fevers, night sweats, weight loss, fatigue and malaise - may indicate tumour or infection
95
What can osteoporotic crush fracture lead to?
acute pain and kyphosis
96
How do you manage osteoporotic crush fractures?
Conservative management
balloon vertebroplasty for patients with chronic pain is being tested
97
What is the main difference between cervical nerve root compression and peripheral nerve compression?
Peripheral nerve compression neuropathies will cause symptoms and signs affecting peripheral nerve sensory and motor territories rather than dermatomal and myotomal distributions
98
Which nerve passes through the carpal tunnel?
median nerve along with 9 flexor tendons
99
What are main causes of carpal tunnel syndrome?
anything which causes swelling or compression of the tunnel
1. Idiopathic
2. secondary
i. Pregnancy - symptoms subside after childbirth
ii. diabetes
iii. chronic renal failure
iv. hypothyroidism (myoxderma)
100
which gender is more likely to suffer from carpal tunnel syndrome?
Women - narrower wrists but have similar sized tendons to men
101
What are the signs and symptoms of carpal tunnel syndrome?
1. Aching pain in the hand and arm at night
| 2. Paraesthesiae in thumb, index and middle fingers -relieved by dangling the hand over the edge of the bed.
102
How do you diagnose Carpal tunnel syndrome?
Tinel's test - percussing over the median nerve
Phalen's test - holding the wrists hyper-flexed
103
How do you manage Carpal tunnel syndrome?
Wrist splinting - prevents flexion at night
local steroid injection
surgery: decompression surgery
104
What is cubital tunnel syndrome?
compression of the ulnar nerve at the elbow behind the medial epicondyle (funny bone)
105
What are the clinical features of the cubital tunnel syndrome?
Paraesthesiae in the ulnar 1.5 fingers
tinels test - over the cubital tunnel is usually positive
106
Define spondyloarthropathies.
Family of inflammatory arthritides characterised by involvement of both the spine and joints, principally in genetically predisposed (HLA B27) individuals
107
What are the main conditions associated with the HLA B27 gene?
1. Ankylosing spondylitis
2. Reactive arthritis
3. Crohn's disease
4. Uveitis
108
What is the difference between Mechanical and inflammatory back pain?
mechanical - worsened by activity, typically worst at end of day, better with rest
Inflammatory - worse, with rest, better with activity, significant early morning stiffness. (>30 mins)
109
What are the main clinical features which spondyloarthropathies?
1. Seronegativity ( Rf -ve)
2. HLA B27 associations
3. Axial arthritis- pathology in spine and sacroiliac joints
4. Asymmetrical large-joint oligoarthritis or monoarthritis
5. Enthesitis - inflammation of the site of insertion of tendon or ligament into bone
6. Dactylitis: inflammation of an entire digit, due to soft tissue oedema
7. Extra- articular mainfestations
110
What is Ankylosing spondylitis (AS)?
A chronic inflammatory disease of the spine and sacroilliac joint
more common in men who present earlier (<30 y.o)
111
What are the signs and symptoms of AS?
1. Gradual onset of lower back pain
2. worse during night with spinal morning stiffness relieved by exercise
3. Peripheral arthritis ( shoulders and hips) - rare
4. enthesitis ( especially achilles tendonitis, plantar fascitis at the tibial and ischial tuberosities)
5. Progressive loss of spinal movement ( all direction) - hence decrease in thoracic expansion
Extra articular features:
1. Anterior Uveitis
2. Cardiovascular involvement (aortic valve)
3. Pulmonary involvement ( fibrosis upper lobes - apical fibrosis)
4. Asymptomatic enteric mucosal inflammation
5. Neurological involvement
( rarely A-A subluxation)
6. Amyloidosis
112
How do you diagnose AS?
Modified New York criteria for diagnosing of Ankylosing spondylitis (1992)
1. limited lumbar motion
2. Lower back pain for three months - improved with exercise not rest
3. Reduced chest expansion
4. Bilateral sacroilitis on X-ray (grade 2-4)
or
5. Unilateral sacrolilits on X ray (grade 3-4)
1. MRI allows detection of active inflammation (bone marrow oedema) and enthesitis
2. X-rays show Sacroilitis, syndesmophytes ( bony growth originating inside a ligament) and bamboo spine
3. Bloods - Rise in ESR, CRP and HLA B27 +ve
4. Schober test
113
How do you manage AS?
Exercise, not rest for back ache
TNF alpha blockers for severe AS
local steroid injections for temporary relief
114
Define what Psoriatic Arthritis is. (PsA)
Inflammatory arthritis associated with Psoriasis but 10-15% of patients can have PsA without psoriasis.
115
What are the clinical subgroups of PsA?
1. Symmetrical polyarthritis (like RA)
2. DIP joints
3. asymmetrical oligoarthritis with dactylitis
4. Spondylitis (spine involvement) with or without peripheral joint involvement
5. Psoriatic arthritis mutilans
116
What are the signs and symptoms of PsA?
Psoriasis
Nail involvement ( pitting, onycholysis)
Dactylitis
Enthesitis
Extra articular features ( eye disease)
117
How do you diagnose PsA?
Bloods - inflammatory parameters raised and negative RF
X-Rays:
1. Marginal erosions and "whiskering"
2. "pencil-in-cup" deformity ( in severe cases)
3. Osteolysis
4. Enthesitis
118
What is Reactive Arthritis?
A condition in which arthritis and other clinical manifestations occur as an autoimmune response to infection elsewhere in the body
119
What are the signs and symptoms of reactive arthritis?
1. Inflammatory synovitis
2. Iritis ( ocular lesions)
3. Keratoderma Blenorrhagica - brown raised plaques on soles and palms
4. Circinate Balanitis - painless penile ulceration
5. Mouth ulcers
6. Enthesitis
7. Reiter's syndrome - urethritis, arthritis and conjunctivitis
8. Fever, fatigue and malaise
120
What are the most common infections associated with Reactive arthritis?
Urogenital e.g. chlamydia
Enterogenic - salmonella, shigella and Yersinia
121
How do you diagnose Reactive arthritis?
ESR and CRP increase
culture stool if diarrhoea
Culture of blood and rine
HLA B27 positive
Joint fluid analysis - rules out infection
X-ray of affected joints
122
How do you manage reactive arthritis?
No specific cure
splint affected joints acutely treat with NSAIDs or Local steroid injections
if symptoms > 6 months then use methotrexate
123
What conditions are associated with Enteric arthropathy?
1. IBD
2. GI bypass
3. Coeliac disease
4. Whipple's disease
124
What are the signs and symptoms of Enteric arthropathy?
Arthritis in several joints (especially in the knees, ankles, elbows and wrists)
1. GI - loose, stool with mucous and blood
2. Weight loss, low grade fever
3. Uveitis
4. Pyoderma gangrenosum
5. Enthesitis
6. Oral ulcers
125
How do you diagnose Enteric arthropathy?
1. Upper and Lower GI endoscopy with biopsy showing Ulceration/ colitis
2. Joint aspirate - no organisms or crystals
3. Raised inflammatory markers - CRP, PV
4. X-Ray/MRI shows sacroiliitis
5. US shows synovitis
126
What is Polymyositis and Dermatomyositis?
Rare conditions characterised by insidious onset of progressive symmetrical muscle weakness and autoimmune-mediated striated muscle inflammation
127
What are the signs and symptoms of Dermatomyositis/Polymositis?
Muscle weakness
insidious onset, worsening over months
symmetrical, proximal muscles
often specific problems e.g. brushing hair and climbing stairs
Myalgia +/- arthragia
2. Dermatosysositis - myositis plus skin signs
1. Macular rash - shawl sign is +ve if over back and shoulders
2. Lilac- purple rash on eyelids often with oedema
3. Nailfold erythema
lungs - ILD and respiratory muscle weakness
Dysphagia
Myocarditis
maligancy in 15% of dermatomyositis and 9% in polymyositis
128
How do you diagnose Dermatomyositis/Polymositis?
Muscle enzymes ( ALT,AST, LDH and CK) increase in plasma
muscle biopsy confirm diagnosis
Autoatibodies - anti Mi2, anti-Jo1 associated with acute onset and ILD
Confrontational ( direct testing of power) and Isotonic testing ( sit and then stand)
EMG ( electromyography) shows increases fibrillations and abnormal motor potentials
MRI shows muscle inflammation, oedema, fibrosis and calcification
129
How do you manage Dermatomyositis/Polymositis?
Corticosteroids ( e.g. prednisolone)
Immunosuppression e.g. Azathioprine, Methotrexate, ciclosporin, IV immunoglobulin and Rituximab
130
What are the clinical features of Polymyalgia rheumatica (PMR)?
Age >50yrs subacute onset
Ache in shoulder and hip girdle and morning stiffness
bilateral aching
fever
weight loss
anorexia
depression
muscle strength is normal
131
What are the clincial features of Giant cell arteritis (GCA)?
Headache
Scalp tenderness
jaw claudication
Visual loss ( amaurosis fugax)
Tender, enlarged, non - pulsatile temporal ateries
132
How do you diagnose PMR and GCA?
Raised ESR and CRP
AlkP raised in 30% of cases
Temporary artery biopsy
Temporal artery USS
133
How do you manage PMR and GCA
PMR: Prednisolone - start at 15mg daily
GCA: Prednisolone - start at 40-60mg daily
gradual reduction in steroid dose over 18 months to 2 years
NSAIDs not effective
134
What is Fibromyalgia?
Common cause of chronic MSK pain not associated with inflammation
commonest cause of MSK pain in women and 6:1 more likely in women too.
135
What might occur before fibromyalgia?
Emotional or physical trauma
136
What are the main risk factors of fibromyalgia?
Female sex
middle age
low household income
divorced
low educational status
137
What are the main conditions associated with fibromyalgia?
Chronic fatigue syndrome
IBS
chronic headaches syndromes
138
What are the signs and symptoms of Fibromyalgia?
Central
1. Chronic headaches
2. sleep disorders
3. Dizziness
4. Cognitive impairment
5. memory impairment
6. Anxiety
7. Depression
Eyes
1. Vision
2. Problems
Systemic
1. pain
2. weight gain
Joint dysfunction of jaw
chest pain
Myofascial pain
1. fatigue
2. twitches
Morning stiffness in joints
problems with urinating
139
How do you diagnose Fibromyalgia?
All normal
Diagnosis is clinical
ACR proposed diagnosis criteria:
1. Patient experiences wide spread pain and associated symptoms
2. Symptoms have been present at same level for >3 months
3. No other condition otherwise explains the pain
140
How do you manage Fibromyalgia
1. Patient education
2. Multi-disciplinary response
3. Graded exercise programme
4. cognitive behavioural therapy
5. Anti- depressants e.g. SSRIs
6. Analgesia
7. Gabapentin and pregabalin
141
Where does Hip pathology typically produce pain?
In the groin which may radiate to the knee
142
What are the complications of a Total hip replacement?
Early local complications: Infection, dislocation, nerve injury of sciatic nerve, leg length discrepancy, DVT and PE.
Late local complications: Early loosening, late infection and late dislocation (due to component wear)
143
What are the causes of Avascular necrosis ( AVN) in the Hip joint?
Primary/idiopathic
Secondary causes include:
Alcohol abuse
Steroids
Hyperlipidaemia
Thrombophilia
144
What are the clinical features of AVN of the hip?
Groin pain
early cases may see only changes on MRI
Later cases show patchy sclerosis on weight bearing area of femoral head with a lytic zone underneath formed by granulation tissue from attempted repair.
Lytic zones form the 'hanging rope sign' on XRAY
The femoral head may then collapse with irregularity of the articular surface and subsequent secondary OA occurs.
145
How do you manage AVN of the hip?
If condition detected early - pre collapse then drill holes can be used in the femoral neck and abnormal area of head to relieve pressure ( decompression)
Once collapse has occurred, then THR only option
146
What is gluteal cuff syndrome?
Broad tendinous insertion of abductor muscles of the hip ( Mainly gluteus medius) is under strain and is affected by tendonitis and degeneration leading to tears.
147
What are the signs and symptoms of gluteal cuff syndrome?
Patients have pain and tenderness in the region of the greater trochanter with pain on resisted abduction
148
How do you manage Gluteal cuff syndrome
Analgesic and anti inflammatories
physiotherapies and steroid injections
No surgery! - no benefit
149
When would you perform a Unicompartimental knee replacement (UKR)?
When the patient has isolated OA of the medial or lateral compartments of the knee as a less invasive surgery with less bone removal and preservation of the knee ligaments.
150
What are the risks of surgery for knee replacements?
Infection
thrombosis
unexplained pain- higher in Total knee replacement than total hip replacement
151
What are the main causes of meniscal tears of the knee?
Most common cause in sports injury for young patients e.g. squatting position
atraumatic spontaneous degenerate tears more likely to happen in older patient
152
What are the clinical features of a meniscal tear of the knee?
Medial meniscal tears more likely than latera meniscal tears - medial meniscus more fixed and less mobile
Knee pain - on the tibial rotation localising the affected compartment (Steinmann's test)
Effusion
Joint line tenderness
Acute Locked knee signifies displaced 'bucket handle' meniscal tear (15 degrees springy block to full extension). Also called knee locking
153
How do you diagnose Meniscal tears?
Imaging :
MRI - gold standard
X RAY - used if associated fracture is suspected
McMurray's test positive
Classification: many types of meniscal tears with differing patterns
1. Longitudinal tears
2. Radial tears
3. Oblique tears
4. Horizontal tears
5. "bucket handle tear" - long longitudinal tear.
154
What is a meniscus tear?
A tear of a meniscus is a rupturing of one or more of the fibrocartilage strips in the knee called menisci.
155
What is a degenerate meniscal tear?
When the meniscus tears spontaneously/ with seemingly innocuous injury
occurs as the meniscus weakens with age
156
What does degenerate meniscal tear suggets?
1st stage of Knee osteoarthritis
157
How can you differentiate between acute and degenerate meniscal tears?
Degenerate tears are Steinmann's negative and are likely to be associated with early symptoms and signs of OA
158
How do you manage meniscal tears?
90% of meniscal tears are not suitable for repair
Depends on presentation of meniscal tear
1. Locked Knee - urgent arthroscopic meniscal surgery indicated
2. Acute Injury with Meniscal target (MRI) - Meniscal preservation may be appropriate or arthroscopic meniscal surgery
3. Meniscal target (MRI) with signs and symptoms of tear -
i. if symptoms >3 months than consider Non-urgent Arthroscopic Partial Meniscectomy
ii. If symptoms <3 months than consider Optimal Non operative treatment and Re assess e.g. Phyisotherapy, steroid injection and analgesia
4. Possible Meniscal target with signs and symptoms of tear - further non surgical treatment is first line e.g. physiotherapy, steroid injection and analgesia
5. Advanced Structural OA and Meniscal tear ( Arthritic symptoms/signs only) :
NO arthroscopic meniscal surgery. Removal of meniscal tissue may increase stress on already worn surfaces.
Physiotherapy, Provide information, weight loss, steroid injection and analgesia
159
What are the main causes of ACL rupture?
Sports injury e.g. Football, rugby and Skiing
160
What are the clinical features of ACL rupture?
Main complaint is rotatory instability with giving way on turning
Knee pain
Swelling (haemarthrosis or effusion)
161
How do you diagnose an ACL rupture
Tests:
Lachman test
Anterior drawer test
Pivot shift test - needs a relaxed patient and cause pain so only a specialist should do it
MRI
X RAY
162
What is 'rule of thirds' in regards to ACL ruptures?
1/3 of patients compensate and are able to function after a ACL rupture
1/3 of patients avoid instability by avoiding certain activities after a rupture
1/3 of patients do not compensate and have frequent instability or can't get back to high impact sport
older patients more likely to compensate
163
How do you manage ACL rupture?
Physiotherapy to strengthen give procioceptive training to the quadriceps and hamstrings muscles may help compensation
Older patients are more likely to compensate or cope with ACL deificent knee
Primary repair not effective in 40% of patients with ACL rupture and end up with having a reconstruction
Surgery ( reconstruction)
Required for professional sportsmen or young adults who are keen on high impact sport
however: does not treat pain nor prevent arthritis
Involves tendon graft being passed through tibial and femoral tunnels at the usual location of the ACL in the knee and secured to the bone.
Intensive rehabilitation is required and may take up to a year to recover and play sports again
164
What occurs in the PCL rupture?
Direct blow to the anterior tibia or hyperextension injury
causes include Motorbike accidents or Dashboard injury
165
What are the clinical features of a PCL rupture?
Popliteal knee pain and Bruising
isolated PCL rupture rare - occurs with other injury normally
there is instability of the knee joint and it is giving when the tibia is pushed posteriorly
positive posterior drawer test
Patients complain about being unstable when walking down the stairs
166
How do you manage a PCL rupture?
PCL reconstruction usually occurs for multiple ligament injured knee
only consider surgical reconstruction of PCL rupture of those with severe Laxity and recurrent instability with frequent hyperextension or feeling unstable descending stairs
Surgical reconstruction - cadaveric Achilles tendon allograft
167
How do you grade Knee ligament injuries?
Grade 1: sprain - tear some fibres but macroscopic structure intact
Grade 2: Partial tear - some fascicles disrupted
Grade 3 - Complete tear
168
Why is a MCL tear not necessarily bad?
Fairly forgiving knee ligament with healing expected in the majority of cases with little or no instability
169
What are the clinical features of a MCL tear?
Laxity and pain on valgus stress
Tenderness over the origin or insertion of the MCL
170
How do you manage MCL tears?
Physiotherapy, rarely requires surgery. Should recover properly ( even with complete tear) unless combined with an ACL or PCL rupture
Acute tears - hinged knee brace
chronic MCL instability - MCL tightening or reconstruction with tendon graft
171
What are the clinical features of LCL ruptures?
common to occur with PCL or ACL injury
Hyperextension and varus gives rise to injury
Pain
tenderness
Injury to common peroneal nerve from excessive stretch is high
Popliteal artery injury is common
172
How do you manage LCL ruptures?
Complete rupture needs urgent repair if early ( 2-3 weeks)
Later reconstruction is required ( hamstring or other tendon)
173
What do complete knee dislocations cause?
Rupture of all four knee ligaments and have a high incidence of neurovascular injury
174
What are the clinical features of a Knee dislocation?
knee Pain
out of place joint
Popliteal artery injury - tear, intimal tear or thrombosis
Nerve injury - common peroneal nerve
compartment syndrome - increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space
175
How do you manage Knee dislocation?
External fixation for temporary stabilsation
Regular checks on the circulation of the foot are mandatory due to risk of thrombosis
Distal circulation concerns - vascular surgery assessment with stenting or by pass may be required
compartment syndrome - requires reperfusion especially after prolonged ischaemia. Fasciotomies may be necessary
Multiple ligament reconstruction common
176
Who are most likely to be affected by patellar dislocation?
females have higher incidence
Adolescents
ligamentous laxity (loose ligaments)
Valgus knee- characterized by hip adduction and hip internal rotation
torsional abnormalities
177
What are the causes of Osteochondral and chondral injuries?
Impaction of the articular surfaces
Direct blow ( patellar dislocation can lead to these types of injuries)
178
What are the clinical features of Osteochondral and chondral injuries?
Knee pain
effusion
179
How do you diagnose Osteochondral and chondral injuries?
XRay
MRI
Arthroscopy
180
How do you manage Osteochondral and chondral injuries?
Acute injuries with large osteochondral fragments should be fixed with pins
Non-weight bearing areas or have little bone attached should be removed arthroscopically
Fibrocartilage ( scar type hyaline cartilage) may fill in the defect in the surface of the knee
microfracture - Bare bone defects can have drilled or holes made to induce bleeding. this promotes fibrocartilage formation from stems cells differentiating into chondroblasts
181
What does the extensor mechanism of knee consist of?
| from most distal to most proximal
Tibial tuberosity
Patellar tendon
Patellar
quadriceps tendon
quadriceps muscles
182
What causes extensor mechanism ruptures?
Rapid contractile force ( e.g. lifting a heavy weight, falling over or spontaneously in a severely in a degenerate tendon)
patellar tendon ruptures occur in a younger age group (<40)
Quadriceps tendon ruptures occur in older patients (>40)
183
What are the risk factors of extensor mechanism ruptures?
1. History of tendonitis
2. Chronic steroid use
3. Diabetes
4. RA
5. chronic renal failure
184
How do you diagnose Extensor mechanism ruptures?
Straight leg raise to determine if the extensor mechanism is intact
Obvious palpable gap in the extensor mechanism
Xrays reveal a high Pt rupture or low lying patella
US used for obese patients if Gap is not obvious
185
How do you manage Extensor mechanism ruptures?
Surgical:
1. Tendon to tendon repair
or
2. Reattachment of the tendon to the patella
steroid injections for tendonitis of the extensor mechanism of the knee MUST BE AVOIDED due to high risk of tendon rupture
186
What is Patellofemoral dysfunction?
Describes disorders of the patellofemoral articulation in anterior knee pain
187
What are the clinical features of patellofemoral dysfunction?
Chondromalacia patellae ( softening of the hyaline cartilage)
Anterior knee pain - worse down hill
lateral patellar compression syndrome
Grinding or clicking sensation at the front of the knee and stiffness after prolonged sitting
188
What are the risk factors for patellofemoral dysfunction?
1. females (particularly in adolescents) - wider hips
2. Joint hypermobility
3. Genu valgum (knock knee)
4. femoral neck anteversion
189
how do you manage Patellofemoral dysfunction?
90% of cases improve with physio - aims at rebalancing quadriceps muscles
Taping may alleviate symptoms
Surgery is a last resort - involve releasing a tight lateral retinaculum or tibia tubercle transfer to aid patellar tracking
190
What causes patellar dislocation?
direct blow or sudden twist of the knee
191
how do you diagnose Patellar dislocations?
Small opacification on X RAY suggest medial facet of the patella striking the lateral femoral condle
A lipo- haemarthrosis occurs with characteristic X ray appearance
192
What are the causes of Ankle Osteoarthritis?
Idiopathic/primary
consequence of previous injury e.g. football players
193
What might repeated dorsiflexion of the ankle cause?
Anterior damage with osteophyte formation
194
What are the clinical features of the ankle osteoarthritis?
signs and symptoms of OA
195
How do you manage Ankle OA?
Pain on dorsiflexion may be improved with removal of the anterior osteophytes (cheilectomy)
2 surgical options exist for significant pain from advanced ankle OA:
1. Arthrodesis - is perhaps a more reliable option than ankle replacement
2. Ankle replacement - may afford better functional outcome due to some preservation of motion. Issue is large force placed on relatively small bones
196
What is Hallux Valgus?
Deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
197
What are the risk factors of Hallux valgus?
More common in females 4:1
familial tendency
Incidence increases with age
commoner with Rheumatoid arthritis
Commoner with multiple sclerosis
Commoner with cerebral palsy
198
What are the clinical features of Hallux valgus?
Painful due to bunion formation - joint incongruence and a widened forefoot may cause rubbing of the foot in an inflamed bursa over the medial 1st metatarsal head
Ulceration and skin breakdown
Hallux can override second toe in severe cases
199
How do you diagnose Hallux Valgus?
X-Ray
200
How do you manage Hallux valgus?
2 forms: operative and non operative
Operative:
Indications - failure of non op, pain, lesser toe deformities, Lifestyle limitation , overlapping, ulceration, functional limitation
many osteotomies required - realigns the bones and soft tissue procedure to tighten slack tissues and release tight tissues
Non operative: shoe modifications ( make wider or padding) spacer in the first web space to stop rubbing too.
201
What is Hallux rigidus?
OA of the first MTPJ
202
What are the causes of Hallux rigidus?
idiopathic or secondary due to osteochondral injury
203
How do you manage Hallux rigidus?
Conservative treatment: wearing stiff soled shoe to limit motion at the MTPJ. A metal bar can be inserted into sole of shoe.
dorsal osteophytes removal via cheilectomy can also help
Arthrodesis is "gold standard" surgical treatment: Prevents women from wearing high heals.
can also have joint replacement
204
What is Morton's neuroma?
Degenerative fibrosis of digital nerve near it's bifurcation. Irritated nerves become inflamed and swollen
205
What are the clinical features of Morton's neuroma?
Women more likely as they wear high heels
Burning pain tingling radiating into the affected toes
Third interspace nerve most commonly involved followed by the second
206
How do you diagnose Morton's neuroma?
Loss of sensation in the affected web space
Mulder's click test
US for demonstrating a swollen nerve
207
How do you manage Morton's neuroma?
Conservative management: Metatarsal pad or offloading insole
Steroid injection can be used to relieve symptoms
Neuroma may be excised
208
What is Osteomyelitis?
Infection of bone including compact and spongy bone as well as the bone marrow
209
What is the pathophysiology of osteomyelitis?
infection causes enzymes from leucocytes cause osteolysis and pus forms
Pus impairs local blood flow making the infection very difficult to eradicate
Sequestrum ( dead fragment of bone) forms and breaks off preventing antibiotics alone from curing the infection
Involucrum ( new bone around the area of necrosis) forms.
Staph aureus can infect osteocytes intracellularly making infection additionally difficult for the system to reach
210
What are the signs and symptoms of acute osteomyelitis?
Usually occurs in children and immunocompromised adults
Septic arthritis occurs
children can form Brodie's abscess ( sub acute osteomyelitis)
Pain in affected bone
fever
211
What are the signs and symptoms of chronic osteomyelitis?
Develops from an untreated acute osteomyelitis
May be associated with sequestrum and/or involucrum
Infection tends to be in the axial skelton ( spine or pelvis) for adults with haematoegenous spread from pulmonary or urinary infections or from disctitis
pain
212
What are the causative organisms for osteomyelitis?
Newborns (<4 months)- S. aureus. Enterobacter sp., Group A and B strep
Children ( 4- 14) S. aureus, group A strep, Haemophilus influenzae and Enterobacter sp.
Adults - S.aureus and occasionally Enterobacter or streptococcus sp
Sickle cell anaemia patients - S.aureus the most common, salmonella is unique for sickle cell anaemia
213
How do you manage osteomyelitis?
Acute - "best guess" antibiotics IV unless there is abscess formation in which then you should use surgical drainage
second line antibiotics if infection fails to resolve or surgery may be performed to gain samples for culture
chronic - antibiotics can be useful in supression. Surgery recommended to gain deep bone tissue cultures to removes any sequestrum and to excise any infected
poorly controlled diabetics, IV drug abusers and other immunocompromised patients are at particular risk of osteomyelitis of the spine. Lumbar spine is the commonest location.
High dose IV antibiotics after CT guided biopsy to obtain culture
214
What nerve is mostly likely to be compressed at:
i. Carpal tunnel
ii. cubital tunnel
i. Median nerve
| ii. ulnar nerve
215
Which takes the slowest to heal after a fracture
humerus
Radius
Tibia
Tibia - takes 16 weeks
216
Which bone has the higher rate of non-union due to retrograde blood supply and avascularity of the bone?
supracondylar fracture
waist of scaphoid fracture
Proximal humeral fractures?
waist of scaphoid fracture
217
Which nerve is most at risk of being damaged by the anterior dislocation of the shoulder?
Axillary nerve
218
Which nerve is most at risk being damaged by the colles (distal radial) fracture?
Median nerve
219
Which nerve is most at risk being damaged by the humeral shaft fracture?
Radial nerve
220
A metatarsal stress fracture can be quickly and easily ruled out by a prompt xray of the affected foot true or false?
False- may not demonstrate a fracture for around 3 weeks until resorption at the fracture ends occurs or callus begins to appear. Bone scan or MRI may be useful to confirm diagnosis
221
What is Myositis Ossificans?
condition where heterotopic ossificiation (bone forming outside the skeleton) occurs in muscles usually after an injury
can form after muscle contusions ( dead leg), fractures (especially elbow) and dislocations ( especially hip dislocation)
222
What is the impingement syndrome?
where the tendons of the rotator cuff ( predominantly the supraspinatus) are compressed in the tight subacromial space during movement producing pain.
223
What are the clinical features of the impingement syndrome?
Painful arc - between 60 to 120 degrees of abduction. can be variable as an inflamed area of supraspinatus tendon passes through the subacromial space.
Pain radiates to the deltoid and upper arm
Tenderness may be felt below the lateral edge of the acromion
224
What are the causes of the impingement syndrome?
Tendonitis subacromial bursitis
Acromioclavicular OA with inferior osteophyte
A hooked acromion rotator cuff tear
225
How do you diagnose impingement syndrome?
Hawkins-Kennedy test (internally rotating the flexed shoulder) - recreates the patient's pain
Cervical radiculopathy should be excluded from history and examination
Imaging - X ray, MRI and US
226
How do you manage Impingement syndrome?
Conservative management: NSAIDs, Analgesics, physiotherapy and subacromial injection of steroid.
Subacromial decompression surgery to create more space for the tendon to pass through.
EITHER : Open procedure - incision large enough to visualise the subacromial space
or
Minimally invasive arthroscopic technique - small instruments and a keyhole camera are inserted into the subacromial space to perform the surgery
227
What are the risk factors of rotator cuffs?
Athletes - throwing events
Manual workers (painters)
Occurs after a sudden jerk ( holding a rail on a bus which stops suddenly)
>40 years of age with pain and weakness
20% of over 60s have asymptomatic cuff tears due to tendon degeneration
228
What are the clinical features of the rotator cuff tears?
Supraspinatous muscle most commonly affected due to its superior location
dull achy pain which gradually increases
Pain present usually in all four tendons of the rotator cuff
tenderness over the shoulder around the glenohumeral joint and the AC joint
Patients tend to have difficulty sleeping on the affected side, reaching overhead e.g. to get something off a high shelf and pain on lifting
Typically have a painful arc with rotator cuff weakness
229
How do you diagnose rotator cuff tears?
Imaging- MRI, US and XRay
Positive impingement signs from tests:
Hawkins-Kennedy test
Jobe's test- also known as the relocation test and empty can test, is an orthopedic examination used to test stability of the shoulder.
Scarf test- scarf test is used to determine the integrity of the acromioclavicular joint
230
How do you manage rotator cuff tears?
Surgery: Rotator cuff repair with subacromial decompression - improves/maintain strength and to prevent subsequent arthritis from chronic cuff deficiency.
Non- operative :
physiotherapy
subacromial injections may help with symptoms
231
What is acute calcific tendonitis?
Results in the acute onset of severe shoulder pain and is characterised by calcium deposition in the supraspinatus tendon
Manage with subacromial steroid and local anaesthetic injection
Condition is self-limiting with pain easing as the calcification reabsorbs
232
What are the two types of shoulder instability?
Traumatic instability
Atraumatic instability- patients with generalised ligamentous laxity ( idiopathic, Ehlers-Danlos, Marfan's)
233
What are the clinical features of bicep tendonitis?
Anterior shoulder pain with pain on resisted biceps contraction
Surgical division of the tendon with or without attachment to the proximal humerus may be required to relieve symptoms.
234
What can cause referred shoulder pain?
neck problems
Angina pectoris
Diaphragmatic irritation
235
What is Lateral epicondylitis ( tennis elbow)
condition where there is pain tenderness over the lateral epicondyle
236
What are the clinical features of the lateral epicondylitis?
Painful and tender lateral epicondyle and pain on resisted middle finger and wrist extension
pain on resisted middle finger and wrist extension
can be a repetitive strain injury
237
How do you diagnose Lateral epicondylitis?
US and MRI
NCS if there any nerve symptoms
Mill's test is positive
238
How do you manage Lateral Epicondylitis?
Usually self limting
Rest from activities that exacerbate pain
Physiotherapy
NSAIDs
Steroid injections
Local anaesthetic injections
Elbow clasp ( brace)
surgical release for refractory cases
239
What is Medial epicondylitis (golfer's elbow)
Condition caused by repeated strain or degeneration of the common flexor origin.
less common than lateral epicondylitis
Usually treated same way as lateral epicondylitis. However injection has risk of injury to the ulnar nerve
240
What is the carpal tunnel syndrome?
condition involving the compression of the median nerve at the wrist as it competes for space along with 9 flexor tendons in the carpal tunnel
more common in women due to smaller wrist sizes
241
What are the clinical features of the carpal tunnel syndrome
Aching pain in the hand and arm - especially at night
Paraesthesia in the thumb, index and middle fingers - relieved by dangling the hand over the edge of the bed and shaking it ( wake and shake)
may be sensory loss and weakness of abductor pollicis brevis
242
what are the causes of the carpal tunnel syndrome?
Anything causing swelling or compression of the tunnel:
myxoedema
prolonged flexion
acromegaly
myeloma
local tumours
RA
amyloidosis
pregnancy
sarcoidosis
243
How do you diagnose carpal tunnel syndrome?
confirm lesion site and severity
Phalen's test- Maximal wrist flexion for 1 min
Tinel's test - tapping of nerve at the wrist can induce tingling
244
How do you manage carpal tunnel syndrome?
splinting
Local steroid injection
decompression surgery
245
What is cubital tunnel syndrome?
Condition involving compression of the ulnar nerve at the elbow behind the medial epicondyle ( funny bone area)
246
What are the clinical features of cubital tunnel syndrome?
Patients complain of paraesthesiae in the ulnar 1 1/2 fingers
Weakness of ulnar nerve innervated muscles may be present including the 1st dorsal interosseous (abduction index finger) and adductor pollicis
Tinel's test usually positive
Froment's test positive
247
What are the two main causes for ulnar nerve compression at the cubital tunnel?
Tight band of fascia forming the roof of the tunnel ( osborne's fascia)
Tightness at the intermuscular septum as the nerve passes through or between the two heads at the origin of the flexor carpi ulnaris
248
how do you manage cubital tunnel syndrome?
rest and avoid pressure on nerve
if symptom continues then night time soft elbow splinting
if splinting fails or is chronic then decompression surgery can be used
249
What is Dupuytren's contracture?
profilerative connective tissue disorder where the specialised palmar fascia undergoes hyperplasia causing finger contractures at the MCP and PIP joints
250
what is the pathophysiology of Dupuytren's contracture
proliferation of myofibroblast cells and the production of the abnormal collagen ( type 3 instead of type 1).
skin of the hand may appear to be puckered.
Palpable nodules may be present
Ring and little fingers most likely affffected
251
What are the risk factors of Dupuytren's contracture?
Men more common
positive family history
smoking
alcohol
heavy manual labour
trauma
diabetes
Phenytoin
Peyronie's diseases ( penis effecting disease) and Ledderhose disease also associated
252
How do you manage Dupuytren's contracture?
Collagenase injections
more than 30 degrees of contracture at PIP joint is an indication of surgery
either have:
fascietomy - removal of diseased tissue
Fasciotomy - removal of division of cords
253
What is trigger finger?
Refers to tendonitis of a flexor tendon to a digit. Results in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck.
middle finger and ring finger most affected
254
what are the clinical features of trigger finger?
Clicking sensation can be heard when fingers move
Pain in fingers
fingers may lock up in fexed position
patients may force finger to regain extension which can be painful
255
How do you manage trigger finger?
steroid injection
surgery for persistent and recurrent cases
256
What are the three stages of RA in the hands?
1. synovitis and tenosynovitis - inflammation within the joints and the tendon sheath lead to swelling and pain in the affected structures
2. Erosions of the joints - inflammatory pannus denudes the joints of articular cartilage
3. Joint instability and tendon rupture - following the progressive destruction of the bony and soft tissue structures in the hand patients can progress to subluxation and chronic tenosynovitis predisposes to extensor tendon ruptures.
257
What are ganglion cusys?
Common mucinous filled cysts found adjacent to a tendon or synovial joint.
258
What are the clinical features of a ganglion cyst?
Common in the hand (DIP joint - mucous cyst)
common in the wrist ( volar wrist ganglion or dorsal wrist gangion)
can occur in the foot, ankle and knee ( baker's cyst)
Localised pain/irritation
scars after removal may become tender
cysts are firm, smooth and rubbery
259
How do you manage Ganglion cysts?
Needle aspiration ( watch out for radial artery if patient has a volar ganglion)
Surgical excision may be required if the swelling causes localised discomfort
DO NOT try to burst
recurrence rate very high if cyst is burst but wall of cyst is not removed
260
What is the giant cell tumour of the tendon sheath?
second most common soft tissue swelling of the hand after ganglions.
usually found on the palmar surface around the PIP joints of index and middle fingers
261
What are the clinical features of the giant cell tumour of the tendon sheath?
Brown
can cause pain
typically well circumscribed can be diffuse
can envelope the digital nerve/artery which can erode into bone
262
What is the histology of giant cell tumour of the tendon sheath?
Contain multinucleate giant cells and haemosiderin (gives it a brown appearance)
263
How do you manage giant cell tumour of the tendon sheath?
Excision to prevent local spread
recurrence can occur
264
What is a pseudotumour?
Inflammatory granuloma produced in response to metal wear particles in the context of a joint replacement, which may be locally invasive but canont metastasise.
265
The principal sign of adhesive capsulitis is what?
loss of external rotation of the shoulder
cant internally rotate or abduct too
266
What are the risk factors of septic arthritis?
Pre-existing joint disease ( especially RA)
Diabetes
immunosuppression
chronic renal failure
prosthetic joints
joint surgery
IVDU
age >80 also more common in children than adults
267
what are the signs and symptoms of septic arthritis?
Severely painful joints
signs of inflammation
tender joints
painful when moved
268
what are the common causes of septic arthritis?
Staph aureus - most common cause in adults
streptococci - second most common cause
Haemophilus influenzae - now uncommon in areas where haemophilus vaccination is used. otherwise most common for kids
neisseria gonnohrea - rare in western europe
E.coli - found with elderly, IVDU and immunocompromised
269
How do you diagnose septic arthritis?
urgent joint aspiration - frank pus then it is most likely septic arthritis
synovial fluid microscopy and culture
plain radiographs and crp may be normal
blood cultures
main differential diagnosis: crystal arthropathies
270
How do you manage septic arthritis?
open washout used to decrease the bacterial load throughout the joint
antibiotics for gram positives e.g. flucloxacillin, vancomycin
271
what is Slipped Upper Femoral Epiphysis (SUFE)?
ii. what is the main long term risk of SUFE?
when the head of the femur (thigh bone) slips off in a backwards direction, for reasons that are not known. It usually happens around puberty between the ages of 11 and 17 years and is more common in boys than girls
ii. Secondary OA
272
which nerve is most at risk of damage from a middle of the humeras fracture?
radial
273
adhesive capsulitis is more common in diabetics than non diabetics true or false?
true
274
What is Takayasu's arteritis?
is an inflammatory and stenotic disease of medium and large sized arteries
275
what is the clinical presentation of Takayasu's arteritis?
mainly in young women
Strong predilection for the aortic arch and its branches
malaise
fever
night sweats
arthralgia
anorexia
weight loss
absent pulse
arterial bruits
discrepancies in blood pressure
276
what is the clinical presentation of multiple myeloma?
Bone pain - secondary to lytic lesions
confusion - secondary to hypercalcaemia
pancytopenia with macrocytosis
renal impairment
hyperclacaemia
ESR >100 mm/hour
277
how do you diagnose multiple myeloma?
plain radiographs of all painful bony areas- to confirm lytic lesions
urinary bence- jones proteins
serum electrophoresis
278
what are the five main subtypes of psoriatic arthritis?
1. Rheumatoid arthritis- like : symmetrical polyarthropathy
2. Asymmetrical arthritis: can affect any joint in the body: often a milder form
3. distal arthritis: occurs in distal joints of fingers and toes; nail changes are common can lead to sausage shaped digits
4. Spondylitis: inflammation of the neck and sacro-iliac joint- often HLA-B27 positive
5. arthritis mulitans: severe destructive arthritis affecting small joints, erosisons develop quickly leading to deformity
279
what is Felty's syndrome?
RA
neutropenia
Splenomegaly
280
which condition is a saddle nose deformity associated with?
GPA
281
what is CREST syndrome?
Calcinosis - formation of calcium deposits in soft tissue
Raynaud syndrome - feel numb and cold in response to cold weather and stress
Oesophageal dysmotility
Sclerodactyly - hardening of the skin of the hand causing fingers to curl inward.
Telangiectasia
